1. Tailoring Systematic Reviews to Meet Critical Priorities in Maternal Health Presented by Meera Viswanathan, Ph.D. RTI International Presented at The 135th Annual Meeting of the American Public Health Association Washington, DC, November 3–7, 2007
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2. Current Practice for Selecting Topics for Systematic Reviews
AHRQ topics often generated by professional societies; Cochrane reviews by individual reviewers
Topic nominations can be motivated by
Search for evidence to review ongoing changes in clinical practice
Publication of unexpected trial or observational data
Incremental approach
Requires clear specification of Patient, Intervention, Comparators, Outcomes, Timing, and Setting (PICOTS)

3. Rethinking Systematic Review Resources on Maternal Health: why should we care?
Systematic reviews can have substantial impact on practice
physician guidelines
quality of care initiatives
Time- and resource-intensive efforts
AHRQ reviews are funded by public dollars

4. Reframing Maternal Health Priorities for Systematic Reviews
TABLE 1—Maternal Morbidity During Labor and Delivery: National Hospital Discharge
Survey, 1993–1997
Women Giving 95% Confidence Estimated
Type of Morbidity Birth, % Interval Annual No.a
Obstetric complications
Hemorrhage
Antepartum ,
Postpartum ,
Preeclampsia and eclampsia
All ,
Severe preeclampsia ,
Eclampsia ,
Transient hypertension of pregnancy ,
Obstetric trauma
3rd/4th-degree laceration or hematoma ,
4th-degree laceration ,
Other obstetric trauma ,
Ruptured uterus ,
Infection
Genitourinary infection ,
Amnionitis ,
Other infection ,
Fever ,
Major puerperal infection ,
Postpartum fever of unknown origin ,
Sepsis < ,
Other
Other puerperal complication ,
Other major obstetric complication ,
Anesthesia complication ,
Wound complication ,
Deep venous thrombosis < ,
Gestational liver disease < ,
Late vomiting < ,
Pulmonary or amniotic embolism < ,
Cerebrovascular accident < ,
Gestational diabetes (abnormal GTT) ,
Preexisting medical conditions
Chronic hypertension ,
Cardiac disease ,
Asthma ,
Diabetes (excluding abnormal GTT) ,
Renal disease ,
Obstetric complications, total ,
Preexisting medical conditions, total ,
Any morbidity, excluding cesarean ,
Cesarean delivery ,
Total morbidity ,
Note. The total sample of deliveries was Individual women were counted only once, no matter how many
complications they had. Therefore, summary prevalence estimates are not the sum of the individual types of morbidity listed
but represent the percentage of women with at least 1 reported morbidity within a given category. GTT = glucose tolerance test.
aBased on total US births (n = ).
TABLE 1—Maternal Morbidity During Labor and Delivery: National Hospital Discharge
Survey, 1993–1997
Women Giving 95% Confidence Estimated
Type of Morbidity Birth, % Interval Annual No.a
Obstetric complications
Hemorrhage
Antepartum ,
Postpartum ,
Preeclampsia and eclampsia
All ,
Severe preeclampsia ,
Eclampsia ,
Transient hypertension of pregnancy ,
Obstetric trauma
3rd/4th-degree laceration or hematoma ,
4th-degree laceration ,
Other obstetric trauma ,
Ruptured uterus ,
Infection
Genitourinary infection ,
Amnionitis ,
Other infection ,
Fever ,
Major puerperal infection ,
Postpartum fever of unknown origin ,
Sepsis < ,
Other
Other puerperal complication ,
Other major obstetric complication ,
Anesthesia complication ,
Wound complication ,
Deep venous thrombosis < ,
Gestational liver disease < ,
Late vomiting < ,
Pulmonary or amniotic embolism < ,
Cerebrovascular accident < ,
Gestational diabetes (abnormal GTT) ,
Preexisting medical conditions
Chronic hypertension ,
Cardiac disease ,
Asthma ,
Diabetes (excluding abnormal GTT) ,
Renal disease ,
Obstetric complications, total ,
Preexisting medical conditions, total ,
Any morbidity, excluding cesarean ,
Cesarean delivery ,
Total morbidity ,
Note. The total sample of deliveries was Individual women were counted only once, no matter how many
complications they had. Therefore, summary prevalence estimates are not the sum of the individual types of morbidity listed
but represent the percentage of women with at least 1 reported morbidity within a given category. GTT = glucose tolerance test.
aBased on total US births (n = ).
Reframing Maternal Health Priorities for Systematic Reviews
Morbidity and mortality
Cross-cutting issues
Cost
Other?

5. Maternal Mortality Issues
Pregnancy-related mortality ratio in the U.S. not declined since 1982
Pregnancy-related mortality ratio in the U.S.: 11.5
Range for industrialized countries 8 – 13
Pregnancy-related mortality likely underestimated when derived from death certificate data
Racial and ethnic disparities persist
Black women have a 4-fold higher risk

6. Prevalence of maternal morbidity during childbirth (1993-1997)
Third- and fourth-degree lacerations: 5.0%
Other obstetric traumas including cervical lacerations and pelvic trauma: 3.8%
Preeclampsia and eclampsia: 3.0%
Gestational diabetes: 2.8%
Genitourinary infections: 2.7%
Postpartum hemorrhages: 2.0%
Amnionitis: 2.0%
Cesarean delivery: 21.8%
Danel, I.; Berg, C.; Johnson, C. H., and Atrash, H. Magnitude of maternal morbidity during labor and delivery: United States, Am J Public Health Apr; 93( 4), p. 632.

7. Prevention of Adverse Events versus Reduction of Harms
Events on morbidity-to-mortality continuum could be due to
Pre-existing conditions
Childbirth
Harms associated with childbirth-related interventions
Potentially preventable adverse events associated with childbirth include
fetal malpresentation, perineal trauma, infection associated with premature rupture of membranes, etc.
Harms associated with childbirth-related interventions include
hyperstimulation from labor induction, hypotension from anesthesia, anal sphincter injury from episiotomy, etc.

8. Systematic Review Priorities in the Intrapartum Period
Review strategies to reduce morbidity and mortality
Focus on prevention of childbirth-related adverse events as well as reduction of harms from childbirth-related intervention
Identify interventions to address persistent disparities in health outcomes

9. Methods: inclusion criteria
Medline search of MeSH term “Delivery, obstetric”
only items with abstracts
English
published in the last 5 years (Jan 2002 to Jan 2007)
meta-analysis or systematic review
female
humans
488 abstracts
Inclusion criteria
Identifiable as systematic review
Relevant to interventions in the intrapartum period

10. Methods: exclusions 108 potential includes
99 available as full-text articles
35 excluded on full-text review
No quality appraisal: 12
Duplicates: 4
Exclusions for content: 19
interventions without comparators, outcomes independent of interventions, not associated with interventions in the intrapartum period

11. Systematic Review Content

12. Systematic Reviews on Childbirth-related Interventions

13. Systematic Reviews on Prevention of Adverse Events

14. Systematic Reviews on Diagnosis/Prognosis

15. Analysis of Disparities
None address racial disparities in health outcomes
Sub-analyses generally based on anticipated risk factors
maternal age
obesity

16. Systematic Review Methods
Adverse events and harms are rare and may not be reported in sufficient numbers in small trials
Half the included reviews concluded that their included studies were underpowered to address adverse events
69 percent of systematic reviews chose to limit their inclusion criteria to randomized trials

17. Considerations for the Future
Include large observational studies to address rare adverse events and harms
Address issues of quality in observational studies
Explicitly seek evidence on interventions addressing racial and ethnic disparities in maternal morbidity and mortality